What must a provider document when selecting an E/M code based on time?

When a provider selects an Evaluation and Management (E/M) code based on time, it is essential to document specific details to ensure compliance with coding guidelines. The correct response involves recording the total time spent, confirming that more than 50% of that time was dedicated to counseling or coordinated care, and providing a description of the content discussed during that time.

The rationale behind this requirement lies in the need for clear documentation that justifies the choice of code based on time rather than clinical decisions. This thorough documentation supports the selection of a higher-level E/M service, reflecting both the complexity of the visit and the nature of the services provided. By recording the total time and the specific content of counseling or coordination efforts, it strengthens the audit trail and ensures that the documentation aligns with payer expectations and regulatory requirements.

Without this comprehensive documentation, a provider may not be able to defend the level of E/M service billed should their claims be audited. This highlights the importance of precise and clear documentation in coding practices, ensuring that providers are reimbursed appropriately for the time and services they deliver.